Provider Demographics
NPI:1023180528
Name:ELLIS OAKS DENTAL CENTER LLC
Entity Type:Organization
Organization Name:ELLIS OAKS DENTAL CENTER LLC
Other - Org Name:CHRISTY M FOGLE DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-762-2065
Mailing Address - Street 1:PO BX 12290
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-2290
Mailing Address - Country:US
Mailing Address - Phone:843-762-2065
Mailing Address - Fax:843-762-7735
Practice Address - Street 1:776 DANIEL ELLIS DRIVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412
Practice Address - Country:US
Practice Address - Phone:843-762-2065
Practice Address - Fax:843-762-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24061223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9837Medicaid
SCZ9A9837Medicaid